Tropical Health Matters

The Ministry of Health in Uganda estimates that private, not-for-profit health (PNPH) facilities account for 30% of all facilities in Uganda, and importantly around 85% of these are located in rural communities. USAID’s ACCESS project has demonstrated that FBO health facilities, an important component of the PNPH sector, can play a major role in increasing the delivery and uptake of malaria in pregnancy (MIP) control interventions in the Kasese District of Uganda. The project was a joint effort of ACCESS partners, particularly Interchurch Medical Assistance (IMA) and JHPIEGO.

The project worked with the Uganda Catholic, Muslim and Protestant Medical Bureaus in five health facilities and upgraded the malaria technical skills of all antenatal care (ANC) staff using JHPIEGO training materials. In addition “community owned resource persons” (village volunteers) and religious leaders were trained to help mobilize women to attend ANC. ANC is a key platform for delivering malaria in pregnancy control interventions.

Over the nine-month intervention 27% of women attending ANC were given Insecticide Treated Nets (ITNs), which were supplied by the project. The facilities normally stocked sulfadoxine-pyrimethamine (SP) for intermittent preventive therapy (IPT). By the end of the project the the proportion of ANC attendees receiving their first dose of IPT rose from 43% to 94%, while those receiving IPT2 increased from 27% to 71%. The Uganda Demographic and Health Survey for 2006 found only 50% of pregnant women nationally had received IPT1, and 17%, IPT2.

Often donor in-service training programs focus exclusively on public sector health workers and neglect those in the private and NGO sectors. In many malaria-endemic countries religious mission health services deliver a large portion of care, and as seen in this Ugandan example, can play a major role in delivering malaria in pregnancy control services if their capacity is improved. Fortunately, these FBO facilities did stock SP from which they could plan and deliver IPT. At the time they did not benefit from supplies of ITNs, although the country was receiving ITNs through Global Fund Grants. It is therefore important for National Malaria Control Programs to integrate FBOs and PNPH facilities into both training and commodity supply programs to ensure full protection of pregnant women from malaria. Since this project was done in collaboration with the Ministry of Health (MOH) in Uganda there is hope that collaboration will continue between the faith mission medical boards and the MOH to expand these MIP services to other FBO facilities.

Intermittent preventive treatment (or therapy) in pregnancy (IPTp) with the drug sulfadoxine-pryimethamine (SP) is a key strategy for controlling morbidity and mortality associated with malaria in both pregnant women and newborns. IPTp when given at least twice, one month apart after quickening, reduces maternal anemia, placental malaria, and low birth weight. IPTp with SP has many characteristics of a good public health intervention in that is is relatively low cost, is easy to deliver, and is generally acceptable and available. The longer half-life of SP gives it comparative advantage over alternatives.

Recently questions have arisen about the value of SP as IPT when there are increasing reports of drug resistance when tested and used in children under five years of age. Of note is a lack of study of resistance in pregnant women themselves, which always poses an ethics problem for researchers. WHO African Region issued a statement in 2005 on the efficacy of SP even under conditions of drug resistance in children under 5 and recommended continued use of SP even where resistance levels in children were up to 50%.

To support this position ter Kuile et al. concluded in the June 20th 2007 issue of JAMA that, “In areas in which 1 of 4 treatments with sulfadoxine-pyrimethamine fail in children by day 14, the 2-dose IPT with sulfadoxine-pyrimethamine regimen continues to provide substantial benefit to HIV-negative semi-immune pregnant women. However, more frequent dosing is required in HIV-positive women not using cotrimoxazole prophylaxis for opportunistic infections.” O’Meara et al. further contend that IPTp is unlikely to significantly impact the spread of SP resistant parasites.

While alternative drugs are being considered, none so far are as cheap as SP. These also require more than one dose and thus make directly observed treatment within the context of antenatal care quite difficult. More research is needed to find appropriate substitutes. Basically it is important for countries to continue using SP for IPTp for the meantime, and of course ensure that all pregnant women obtain and sleep under ITNs.

The August issue of Tropical Medicine and International Health demonstrates the fact that malaria control interventions do not implement themselves. Providing commodities is only part of the picture. Ouma et al. representing a team from KEMRI, JHPIEGO, CDC and the University of Amsterdam have shown that coverage of Intermittent Preventive Treatment in Pregnancy is enhanced when health workers received training on focused antenatal care (FANC) and the national malaria guidelines.

“The 3-day training used a competency-based learning approach, emphasizing theory with one full day spent in a clinical setting for practical experience. The training materials included a training/orientation package of two-page laminated service provider job aids on malaria in pregnancy and FANC/MIP and community brochures.”

Ironically in Kenya there had been an IPTp policy since 1998, but without adequate staff capacity building the policy was not achieving results. The situation is similar in other countries.

An assessment for malaria in pregnancy in Akwa Ibom State in southeast Nigeria documented that two years after the national Malaria in Pregnancy Guidelines had been published (2005), front line antenatal clinic staff were not familiar with the term IPT. JHPIEGO has worked with the Federal Ministry of Health to develop the guidelines and an orientation package on FANC and MIP and is now planning to roll out MIP training for the health workers in Akwa Ibom State with support from the ExxonMobil Foundation. Hopefully this will produce similar results as the efforts in Kenya.

In conclusion, national malaria control programs and projects cannot succeed on commodities alone. Health workers need basic orientation and skills to roll back malaria

The Sixtieth Session of the World Health Assembly (WHA) endorsed the creation of Malaria Day to bring global awareness to what has been to date Africa Malaria Day Resolution (A60/12). This follows on the heels of creation of Malaria Awareness Day in the US to compliment Africa Malaria Day. In the process the WHA wound up officially excluded Intermittent Preventive Treatment for pregnant women (IPTp) from the list of key interventions to being simply an activity that is implemented in Africa. This follows elevation by the WHO’s Global Malaria Program of IRS to a key global strategy and demonstrating that pregnant women in Africa are no longer important to the global fight against malaria – just a regional anomaly.

One excuse for demoting IPTp is supposed sulfadoxine-pyrimethamine (SP) resistance. Interestingly it is the same WHO along with researchers who have found that SP for IPTp is effective even at rates of 50% resistance among non-immune children under five years of age. No less an authority than peer reviewed Lancet articles have recently made the case for continuing IPTp with SP. Maybe the WHA has been tricked by people who don’t realize that even in a ‘global’ malaria program, the greatest burden of malaria falls on children and pregnant women in Africa.

The American Journal of Tropical Medicine and Hygiene published a unique article in its May 2007 issue that documents how the timing and number of malaria infections during pregnancy influences child birth weight outcomes in Burkina Faso. Infection after 6 months of pregnancy was the strongest factor associated with low birth weight (LBW), but LBW was also associated with infection in early pregnancy. The challenge in determining the latter is that women in the study, as is the case in much of Africa, tended to register for antenatal care later in pregnancy. Fortunately in this study one-third of the women enrolled had first attended ANC in the first trimester and could be followed longer. This helped provide information for another important finding, that LBW is also more likely when women are infected with malaria multiple times during pregnancy.

These findings highlight the challenges of reaching pregnant women in a timely manner with malaria prevention measures including insecticide treated nets (ITNs) and intermittent preventive therapy during pregnancy (IPTp). The authors note the value of a full course of IPTp in preventing LBW, but lament that there are currently no safe drugs to use for IPTp in the first trimester. An additional challenge is that many women register for ANC too late or attend too infrequently to benefit from at least two doses after quickening at one month apart.

This points to the need to ensure that all ANC clinics have ITNs to give women on their very first visit. For those who attend and are not yet eligible for IPTp, ITNs too, prevent LBW and will provide the protection for the early infections that lead to LBW. Then if a woman gets a net early in pregnancy, she will be less likely to suffer multiple malaria infections, another risk factor for LBW.

The challenge if one of policy versus logistics. Although most malaria endemic countries point to guidelines that say a pregnant should sleep under an ITN, few have figured out the logistics of guaranteeing a regular and dedicated supply of ITNs for ANC clinics. At present ITN distribution favors campaigns as opposed to integration into routine Maternal and Child Health services. While this may favor achieving large targets among children under five years of age, it usually bypasses pregnant women.

Last week a colleague at JHPIEGO suggested that all women of reproductive age should be given an ITN. This would certainly help keep them safe from malaria whenever they get pregnant. Are donors willing to take up this challenge?

A current article by Ye et al. in Malaria Journal stresses that while malaria may be a national problem, there are important local variations in malaria risk in an area of northwestern Burkina Faso. Ecological and economic factors may likely play a role and include seasonal rice farming, cattle rearing, irrigation, and living in a semi-urban area. They conclude that, “malaria control strategies should be designed to fit location-specific contexts.” Just because a community has a different ecological setting or requires a different malaria control strategy does not mean it is not part of the global fight against malaria. One size does not fit all.

This brings to mind discussions over the past year whether intermittent preventive treatment for pregnant women (IPTp) is considered a major strategy by WHO’s Global Malaria Control Program (GMP). As of this date (20 April 2007) right in the center of the GMP web page one finds the following statement: “IRS is now one of three main interventions promoted by WHO to control malaria.” This refers to a 2006 document on Indoor Residual Spraying (IRS), which on page 1 recommends the following three ‘primary’ interventions for the control of malaria:

• diagnosis of malaria cases and treatment with effective medicines;
• distribution of insecticide-treated nets (ITNs) to achieve full coverage of populations at risk of malaria; and
• indoor residual spraying (IRS) as a major means of malaria vector control to reduce and eliminate malaria transmission including, where indicated, the use of DDT.

People have taken this to mean that IPTp is no longer considered to be a primary intervention. Recent discussions with colleagues revealed that there is a school of thought that says since IPTp is a key tool for the African Region, it is not a ‘global’ strategy. They explained that pregnant women are a focus when it comes to ITNs. They note further that there are links to a fact sheet on malaria in pregnancy at the Roll Back Malaria Website that lists IPTp as part of a three-pronged approach to malaria control, as well as a link to WHO’s Regional Office for Africa and its Strategic Framework for Prevention and Control of Malaria During Pregnancy, which also lists IPTp as a major strategy.

While these links to other organizations are helpful, they do not dispel the uncomfortable feeling that pregnant women in Africa do not rate the status of being part of the ‘global’ malaria control effort. One also wonders about their sisters in Papua New Guinea or Brazil where falciparum malaria also is of concern.

If one wants to be particular, one can even question whether the GMP is actually global. What are its strategies for controlling malaria in Norway or New Zealand, for example? Obviously what makes the fight against malaria global is the fact that people and agencies in both endemic and non-endemic countries are joining together to do whatever it takes to control the disease.

Excluding IPTp from the ‘global’ arsenal presents a false distinction and reinforces the perceptions of neglect, which Africa and women’s health have suffered on many fronts for too long. As Ye et al. have found, there is no single global malaria context, and while we have a variety of tools to fight malaria, there is no one magic global bullet to eliminate malaria in every situation. Let’s form a global alliance that recognizes a wide arsenal of malaria tools but adapts them to the local ecology and local needs.

Pregnant women are particularly vulnerable to malaria, which can cause life-threatening anemia, low-birth weight, and even death for the infant. Yet the international public health community seems to be overlooking the risks pregnant women and their unborn children face when infected with malaria. And myths and misperceptions at the country level also hamper effective control of malaria in pregnancy (MIP).

Take a look at the WHO’s Global Malaria Program (GMP) website and you will find that intermittent preventive treatment (IPT) for pregnant women has been replaced by indoor-residual spraying (IRS). Specifically in reference to a new publication on IRS, the website states, “IRS is now one of THREE main interventions promoted by WHO to control malaria,” and a closer reading of that document shows that IPT has been dropped in favor of IRS. Obviously WHO is not dropping MIP interventions, but the fall from grace for IPT in pregnancy is disconcerting when MIP is responsible for morbidity and mortality in both mothers and newborns. This is particularly discouraging since IPT and ITNs for pregnant women have been shown to be highly effective, and are delivered through established ante-natal services, making them an obvious choice for high impact at low cost.

In addition to benign neglect by international health officials, various myths have emerged about MIP interventions at the country level. Front line health workers and mothers in many countries still believe that the drug of choice, sulfadoxine-pyrimethamine (SP), is either unsafe or too strong for pregnant women. A second myth surrounds SP as an appropriate treatment – the news about preventing further drug resistance in the general population by not using SP for curative care has not been heard or heeded, especially when the alternatives, artemisinin-based combination therapy (ACT), is so expensive.

Another myth is that since SP is relatively cheap, there is little need to focus major donor attention on strengthening IPT programming. Finally there is the myth that insecticide-treated nets (ITNs) will certainly reach pregnant women if community campaigns are conducted. Aside from the normal problems of leakage and poor documentation, separating ITN distribution from antenatal care removes an important incentive for women to safeguard their pregnancies through timely prenatal visits.

Recently the Roll Back Malaria Working Group on MIP held its seventh meeting in Abuja, Nigeria. A key recommendation was greater involvement, if not full leadership by the reproductive health (RH) community in the battle against malaria in pregnancy. The close integration of RH and malaria control programs can make sure IPT remains a priority intervention necessary to meet the goals detailed in the Abuja Declaration from 2000.